Review
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►► Additional material is
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1
La Trobe Sport and Exercise
Medicine Research Centre, La
Trobe University, Melbourne,
Victoria, Australia
2
School of Allied Health
Sciences, Griffith University,
Gold Coast Campus,
Queensland, Australia
3
High Performance Unit, Irish
Rugby Football Union, Dublin,
Ireland
Correspondence to
Brady Green, La Trobe Sport
and Exercise Medicine Research
Centre, La Trobe University,
Melbourne, VIC 3086, Australia;
​B.​Green2@​latrobe.​edu.a​ u
Accepted 28 February 2020
Published Online First
16 April 2020
© Author(s) (or their
employer(s)) 2020. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Green B,
Bourne MN, van Dyk N,
et al. Br J Sports Med
2020;54:1081–1088.
Recalibrating the risk of hamstring strain injury (HSI):
A 2020 systematic review and meta-­analysis of risk
factors for index and recurrent hamstring strain injury
in sport
Brady Green  ‍ ‍,1 Matthew N Bourne  ‍ ‍,1,2 Nicol van Dyk  ‍ ‍,3 Tania Pizzari  ‍ ‍1
ABSTRACT
Objective  To systematically review risk factors for
hamstring strain injury (HSI).
Design  Systematic review update.
Data sources  Database searches: (1) inception to 2011
(original), and (2) 2011 to December 2018 (update).
Citation tracking, manual reference and ahead of press
searches.
Eligibility criteria for selecting studies  Studies
presenting prospective data evaluating factors associated
with the risk of index and/or recurrent HSI.
Method  Search result screening and risk of bias
assessment. A best evidence synthesis for each factor and
meta-­analysis, where possible, to determine the association
with risk of HSI.
Results  The 78 studies captured 8,319 total HSIs,
including 967 recurrences, in 71,324 athletes. Older age
(standardised mean difference=1.6, p=0.002), any history
of HSI (risk ratio (RR)=2.7, p<0.001), a recent HSI (RR=4.8,
p<0.001), previous anterior cruciate ligament (ACL) injury
(RR=1.7, p=0.002) and previous calf strain injury (RR=1.5,
p<0.001) were significant risk factors for HSI. From the best
evidence synthesis, factors relating to sports performance
and match play, running and hamstring strength were most
consistently associated with HSI risk. The risk of recurrent
HSI is best evaluated using clinical data and not the MRI
characteristics of the index injury.
Summary/conclusion  Older age and a history of HSI
are the strongest risk factors for HSI. Future research
may be directed towards exploring the interaction of risk
factors and how these relationships fluctuate over time
given the occurrence of index and recurrent HSI in sport is
multifactorial.
Introduction
The hamstrings are involved in a host of athletic
motions that include running,1–3 jumping4 and
kicking.5 6 Hamstring function is important to the
performance of most sport-­related activities, partic-
ularly when fast running is required.2 4–7 Injuries to
the hamstring muscles compromise individual perfor-
mance and team success in many sports.8–13 Awareness
of risk factors for hamstring strain injury (HSI) is an
important component of athlete load management,
injury prevention and return to play decision-­making
post injury.14 15 Previous reviews of risk factors for
injury have identified that older age and a history of
HSI are commonly associated with a greater risk of
future HSI.16–18
Green B, et al. Br J Sports Med 2020;54:1081–1088. doi:10.1136/bjsports-2019-100983
Prospective studies continue to examine a range of
modifiable and non-­modifiable factors to determine
which are most associated with HSI.19–21 Hamstring
strength can now be measured using novel field-­based
procedures,22 such as the Nordic hamstring exercise
(NHE) test.23–25 The relationship between hamstring
strength measured by these devices and HSI risk is
not known.16 26 In a 2018 systematic review, isoki-
netic strength testing did not accurately predict risk of
HSI.26 Whether an athlete’s training load, including
various measures of running workload and match
exposure, increase HSI risk is of interest.27–30
Given the significant body of new research,
we updated our 2013 systematic review16 of risk
factors for sport-­ related index and recurrent
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HSI.31 32.
Method
Search strategy and selection of studies
A systematic search was carried out using Medline,
CINAHL, Embase, AMED, AUSPORT, SportDiscus,
PEDro and the Cochrane Library from 2011 to
December 2018. Previous searches from the original
systematic review captured studies published from
database inception to 2011.16 The studies included
in the original review were included in this update.
An identical search method was used, including
databases searched.16 Keywords derived from the
research question were used to structure the search
and were mapped to medical subject headings where
possible (online supplementary appendix 1). Citation
tracking and manual reference list scanning were
carried out. Ahead of press searching was performed
using key sports medicine journals identified from
database searches (British Journal of Sports Medi-
cine, Scandinavian Journal of Medicine and Science in
Sports, American Journal of Sports Medicine, Sports
Medicine). Acquired references were imported and
duplicates were removed (EndNote V.X3 software,
Thomas Reuters, New York; USA). All reviewers
(BG, MNB, NvD, TP) took part in applying selec-
tion criteria to prospective studies. Consensus was
reached by discussion where required.
Study selection criteria
Participants/injury
Included studies investigated index (ie, a first-­
time injury within the surveillance period) and/
or recurrent HSIs (ie, a second HSI following an
index HSI)31 32 in athletic populations during sport-­
related activities. All studies presented discrete data
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for HSI. Only HSIs were examined; studies examining tendinop-
athy, non-­specific thigh injuries, hamstring origin avulsions and
contusion-­type pathologies were excluded.
Risk factors for HSI
Studies were required to present discrete data for one or more
risk factors and their association with HSI. Intrinsic (eg, age,
injury history, physical qualities) and extrinsic (eg, environment,
stage of the season, competition schedule) factors were included.
Studies reporting data that were not directly examined in rela-
tion to injury risk or the occurrence of HSI were excluded.
Study type
Systematic reviews and studies involving the analysis of
prospectively collected data on non-­ modifiable factors were
included. Intervention studies were excluded to limit potential
confounding. All included studies involved human participants,
were published in English and full-­text versions were available.
Conference abstracts and unpublished data were excluded.
Data collection and analysis
Risk of bias assessment
Three reviewers (BG, MNB, NvD) used a modified version of the
Quality in Prognosis Studies (QUIPS) tool to assess the risk of bias
of all studies that were not systematic reviews. Risk of bias assess-
ment using the QUIPS has been previously described33 34 and has
been utilised in recent HSI-­related systematic reviews.26 35 36 The
QUIPS permits a systematic approach to best evidence synthesis
described in detail later. Two of three reviewers were allocated to
each study (BG, MNB, NvD). Discrepancies between authors in
QUIPS scoring were reassessed and resolved by a third reviewer
to reach consensus.
Six areas of assessment determined the overall risk of bias
for each study: study participation, study attrition, prognostic
Figure 1  Flow diagram demonstrating study selection for the analysis of risk factors for index and recurrent hamstring strain injury.
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factor measurement, outcome measurement, study confounding,
and statistical analysis and reporting (online supplementary
appendix 1). Each area has specific criteria that all studies are
appraised against to identify whether it is a potential source of
bias. Criteria are given a score of either ‘yes’ or ‘no’, and if for
a single category there are less than 75% of ‘yes’ responses, it is
deemed to be a ‘high risk’ of bias for that area of study design.
‘Low risk’ for an area is reached by scoring a ‘yes’ for 75% or
more of the criteria for that single category. A study is then given
an overall risk of bias according to the scores of each area. To be
deemed as a ‘low risk of bias’ study, it must score a ‘yes’ for at
least five categories. It must have also scored a ‘yes’ for the area
relating to outcome measurement (item 4). Studies are otherwise
classed as ‘high risk of bias’.
Data extraction
Data were extracted with a focus on factors evaluated for their
association with index and/or recurrent HSI. Raw data were
extracted according to outcome measurement and the results
reported. Reviewers extracted data relating to the key results,
athletic population, length of tracking, and methods of HSI diag-
nosis and injury classification.
Data analysis and best evidence synthesis
Non-­blinded reviewers (BG, TP) extracted data independently,
including mean values, medians, standard deviations (SDs),
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risk ratios (RRs), odds ratios (ORs) and hazard ratios (HRs).
For continuous data, the difference in the injured and unin-
jured group means were divided by the pooled SD to calculate
standardised mean differences (SMDs) and their accompa-
nying 95% confidence intervals (CIs).37 The SMD indicates
the magnitude of difference between injured and non-­injured
groups for a continuous variable. Where appropriate the RRs
were recalculated from raw data provided. The reported ratios
Green B, et al. Br J Sports Med 2020;54:1081–1088. doi:10.1136/bjsports-2019-100983

and the 95% CI were used when the studies did not provide
adequate frequency data. Comprehensive meta-­analysis V.2.0
(Biostat, Englewood, New Jersey, USA) was used to perform
meta-­analyses from data provided in individual studies for the
potential risk factors for HSI. A random effects model was
used to better account for potential methodological or statis-
tical heterogeneity. Compared to a fixed effects approach,
a random effects model reduces the likelihood of a type two
error by making it more difficult for a result to be determined as
statistically significant. The random effects model offers more
accurate and statistically safer information by generating wider
CIs around pooled effect sizes.37 Heterogeneity was assessed
using the I2 statistic.38 Effect sizes were interpreted as small (0
to 0.20), moderate (0.21 to 0.5) or large (≥0.80). Statistical
significance was set at p<0.05.39
A best evidence synthesis was used to identify the level of
evidence (LOE) and strength of association between each factor
and HSI risk. The best evidence synthesis provided another
source of information in conjunction with findings from the
meta-­analyses. It was used to clarify the relationship with HSI
when heterogeneity or a paucity of raw data did not permit a
meta-­analysis to be performed.26 35 36 For each risk factor anal-
ysed the LOE is determined according to set criteria that includes
information from the risk of bias assessment.40 41 Listed below
are the four hierarchical levels of evidence:
1. Strong evidence: Consistent results in two or more low risk
of bias studies, with generally consistent findings in ≥75%
of studies.
2. Moderate evidence: One low risk of bias study and one or
more high risk of bias studies provide consistent findings, or
consistent findings reported in two or more high risk of bias
studies with consistent results in≥75% studies.
3. Limited evidence: Single study findings from either a high
risk or low risk of bias study.
4. Conflicting evidence: Multiple studies (of either high risk or
low risk of bias) that do not provide consistent results, with
consistent results in<75% studies.
Results
Search results
Initial searches yielded 2759 articles and there were an addi-
tional 42 articles from other sources (citation tracking, ahead
of press searches, manual reference checking). This yield was
reduced to 1685 following removal of duplicates. Screening of
the titles and abstracts resulted in selection of 138 articles for
analysis in full-­text form, and 44 of these articles were deter-
mined to meet the requirements for inclusion. Once combined
with the yield from the original systematic review,16 a final total
of 78 studies were included (figure 1).
Description of the included studies
The most represented athletic populations were: football
(n=26), Australian Football (n=21), and track and field (n=8);
in predominantly male cohorts from the elite level of competi-
tion (elite: 61%, amateur: 23%, mixed: 16%), aged 16–37 years.
Study populations originated from the United Kingdom (UK),
Australia, France, ‘Europe’, Norway, Iceland, Belgium, Brazil,
Qatar, Japan, the United States of America (USA) and the
Netherlands. Across all studies 8,319 total HSIs, including 967
confirmed recurrences, were captured among 71, 324 subjects
(online supplementary table 1).
Green B, et al. Br J Sports Med 2020;54:1081–1088. doi:10.1136/bjsports-2019-100983
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Overview of results of risk of bias assessment (QUIPS)
A low risk of bias was found for 28 studies
(40%).12 20 23–25 27 28 42–62 A high risk of bias was identified in
42 studies (60%)19 21 22 29 30 63–99(table 1). Authors reached full
agreement on risk of bias assessment (BG, MNB, NvD). The
most common potential source of bias was ‘study confounding
variables’ (item 5: 64.3%), which was related to whether poten-
tial confounders were defined, identified and accounted for in
the study design and analysis. Other sources of bias included
study attrition (item 2: 35.7%), study participation (item 1:
31.4%), outcome measurement (item 4: 28.4%), prognostic
factor measurement (item 3: 25.6%), statistical analysis and
reporting (item 6: 18.3%).(table 1) Systematic reviews18 26 100–105
were not subject to the QUIPS tool.
Overview of results from meta-analyses
Twenty-­one potential risk factors were evaluated using meta-­
analysis. From these results, the strongest risk factors for HSI
were older age (figure 2), history of HSI, previous anterior
cruciate ligament (ACL) injury and previous calf strain injury
(figure 3). None of the 13 strength-­related variables were signifi-
cantly associated with risk of HSI (figure 4).
Overview of results from the best evidence synthesis
The best evidence synthesis included 179 factors and their asso-
ciation with index (129 factors) and/or recurrent (50 factors)
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HSI. Forty-­nine factors demonstrated evidence for an associa-
tion with increased risk of HSI (index: 41, recurrent: 8). One
hundred and twelve factors demonstrated evidence for no asso-
ciation with increased risk of HSI (index: 73, recurrent: 39).
Eighteen showed conflicting evidence of an unknown associa-
tion with HSI (index: 15, recurrent: 3) (online supplementary
appendix 2: tables 2-5).
Risk factor evaluation according to key areas of risk
Non-modifiable factors
Older age was associated with a greater risk of HSI from
meta-­analysis of 19 studies (SMD=1.6, 95% CI 0.6 to 2.6,
p=0.002).20 21 23–25 27 42 45 46 50 55–57 60 61 71 73 90 95 (figure 2). A
history of HSI (RR=2.7, p<0.001),23–25 27 47 52 85 88 ACL injury
(RR=1.7, p=0.002),23–25 27 30 knee injury (LOE: moderate),46 95
calf strain injury (RR=1.5, p<0.001)23–25 30 52 and ankle liga-
ment injury (LOE: limited)51 increased the risk of HSI; if the
previous HSI occurred within the same season the risk was even
greater (ie, recent history: RR=4.8, p<0.001)30 52 59 85 (figure 3,
online supplementary appendix 2: table 2). A history of quad-
riceps strain injury23–25 49 and previous chronic groin patholo-
gy/‘osteitis pubis’23–25 95 did not increase the risk of HSI (LOE:
strong) (online supplementary appendix 2: table 3).
Architecture and structure
Athlete (weight, body mass index) and muscle (biceps femoris;24
gluteus maximus, gluteus medius)74 size did not increase the risk
of HSI (figure 2, online supplementary appendix 2: table 3), but
biceps femoris fascicle length24 and hamstring muscle-­tendon
unit stiffness60 were associated with risk of index HSI (LOE:
limited) (online supplementary appendix 2: table 2).
Strength
Reduced hamstring strength qualities, strength endurance
(index: single leg hamstring bridge;46 recurrent: eccentric leg
curl21) and strength (hand held dynamometry; index: eccen-
tric,22 isometric;22 recurrent: isometric44), were associated with
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Table 1  Risk of bias assessment Table 1  Continued
Potential risk of bias item Potential risk of bias item
Study 1 2 3 4 5 6 Risk of bias Study 1 2 3 4 5 6 Risk of bias
Árnason et al42 + + + + + + Low van Dyk et al20 + + + + + + Low
Bengtsson et al63 + – + + – + High van Dyk et al55 + – + + + + Low
65
Bennell et al + – + + – + High van Dyk et al56 + + + + + + Low
Bennell et al64 + + – + – + High van Dyk et al57 + + + + + + Low
Bourne et al23 + – + + + + Low Venturelli et al94 + + + – – + High
Bradley and Portas66 – + + – – + High Verrall et al58 + + + + – + Low
Brooks et al12 + + + + – + Low Verrall et al95 + + + – – + High
Brooks and Kemp67 + – + + – + High Warren et al59 + + + + – + Low
Cameron et al68 – + + – – + High Watsford et al60 + – + + + + Low
Carling et al69 – + – + – + High Witvrouw et al96 – – – – – – High
Christensen and Wiseman70 – – – – – – High Woods et al97 + – – – – – High
Croisier et al43 + + + + – + Low Yamada and Matsumoto98 – + – – – – High
Dauty et al71 + + – + – – High Yamamoto et al99 – – – – – – High
De Vos et al44 + + + + – + Low Yeung et al61 + + + + – + Low
Duhig et al28 + + + + + + Low Zvijac et al62 + + + + – + Low
Elliott et al72 – – + + – – High 1, study participation, 2, study attrition, 3, prognostic factor measurement, 4,
Engebretsen et al45 + + + + + + Low outcome measurement, 5, study confounding variables, 6, statistical analysis and
Fousekis et al73 + + – – – + High reporting.
Frannetovich-S­ mith et al74 + + + + – – High
Freckleton et al46 + + + + – + Low an increased risk of HSI (LOE: limited) (online supplementary
Gabbe et al76 – + – – – + High appendix 2: tables 2 and 5). Eccentric hamstring strength during

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Gabbe et al47 + + + + – + Low the NHE was not associated with risk of HSI from the meta-­
Gabbe et al75 – – + + – + High analysis (SMDabsolute=−0.31, 95% CI −0.97 to 0.4, p=0.13;
Gibbs et al77 + + – + – – High SMDrelative=−0.34, 95% CI −1.1 to 0.4, p=0.14);23–25 55 the best
Goossens et al22 – – – + + + High evidence synthesis identified conflicting evidence of an unknown
Hägglund et al48 + + + + + + Low association (figure 4, online supplementary appendix 2: table 4).
Hägglund et al49 + + + + – + Low In 11 meta-­analyses isokinetic testing was unrelated to HSI risk
Henderson et al50 + + + + + + Low (figure 4).
Iguchi et al78 + + + – – + High
Koulouris et al79 – + – – – – High Power and ballistic function
Lawrence et al80 – + – + – + High Reduced single leg hop for distance22 and the percentage differ-
Lee et al81 – – + + + + High ence between non-­countermovement jump and countermove-
Malliaropoulos et al82 + + – – – – High ment jump94 were associated with risk of index HSI (LOE:
Malliaropoulos et al51 + + + + + + Low
limited) (online supplementary appendix 2: table 2). Other
countermovement jump measures were not associated with
Opar et al83 + + + – – + High
index HSI, such as height (LOE: strong)42 50 78 84 94 and power
Opar et al25 + + + + + + Low
output (LOE: moderate)42 78 (online supplementary appendix 2:
Orchard et al84 + – + + – + High
table 3).
Orchard et al52 + – + + + + Low
Orchard et al29 – – + + – + High
Flexibility, mobility and range of motion
Orchard et al30 – – + + + + High
85
No factor related to flexibility, mobility and range of motion
Orchard et al – + + + – + High
showed a clear relationship with risk of index HSI, including
Pollock et al86 – + + + + – High common hamstring tests: passive knee extension (LOE:
Reurink et al87 – + + – – + High strong),42 45 56 89 91 active knee extension (LOE: strong),47 56 75 76 89 91
Roe et al88 – – + + – + High passive straight leg raise (LOE: strong)50 61 75 89 96 and slump
Rolls and George89 – + + – – + High (LOE: moderate)47 75 76 (online supplementary appendix 2: table
Ruddy et al27 + + + + + + Low 3). A greater active knee extension deficit just after return to
Schuermans et al21 + – – + – – High play increased the risk of recurrent HSI (LOE: limited)44 (online
Schuermans et al90 + – – + + + High supplementary appendix 2: table 5). The relationships between
Schuermans et al91 + – + – – + High reduced hip extension (modified Thomas test)47 75 76 91 and
Schuermans et al92 + – + – – + High ankle dorsiflexion (lunge)46 47 56 75 76 and risk of index HSI were
Sugiura et al53 + + – + + + Low conflicting (online supplementary appendix 2: table 4).
Timmins et al24 + + + + + + Low
van der Made et al93 – – + + + + High Electromyography and motor control
van der Made et al 54
+ + + + + + Low Reduced trunk muscle (cluster of: internal oblique, external
van Doormaal et al 19
+ – + – + + High oblique, thoracic erector spinae, lumbar erector spinae) elec-
tromyographic (EMG) activity during the backswing phase
Continued
of sprinting (LOE: limited)90 and increased gluteus medius

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Figure 2  Meta-­analysis for age, height, weight and body mass index. SMD, standardised mean difference.

EMG activity during running (12 km/hour, 15 km/hour) (LOE:
limited)74 were associated with risk of index HSI (online
supplementary appendix 2: table 2). There were conflicting
findings for gluteus maximus EMG activity while sprinting
and running at a range of submaximal speeds74 90 (online
supplementary appendix 2: table 4). Trunk and hamstring
motor control were associated with index HSI in three studies:
muscle recruitment pattern during prone hip extension (LOE:
limited),91 dominance of biceps femoris recruitment during
a fatiguing eccentric leg curl (LOE: limited)21 and hamstring
movement discrimination (LOE: limited)68 (online supplemen-
tary appendix 2: table 2).
Running-based measurements
Increases in high-­speed running exposure were associated with
a greater risk of index HSI27 28 (online supplementary appendix
2: table 2). Sprinting kinematics were also associated with index

Figure 3  Meta-­analysis for injury history: hamstring strain injury (HSI), ACL injury and calf strain injury. RR, risk ratio.

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Figure 4  Meta-­analysis for strength testing: Nordic hamstring exercise (NHE) and isokinetic variables. Abs., absolute; conc, concentric; Conv.,
conventional ratio; ecc, eccentric; HS, hamstrings; Qu, quadriceps; Rel., relative; SMD, standardised mean difference.
HSI risk in cases of increased thoracic side-­bending during front
swing (LOE: limited)92 and increased anterior pelvic tilt during
backswing (LOE: limited)92 (online supplementary appendix 2:
table 2). Aerobic (VO2 max) (LOE: moderate),42 84 intermittent
running (YoYo) (LOE: moderate),50 94 sprinting (40 m sprint
characteristics) (LOE: moderate)45 84 and agility (LOE: limited)50
test results were not associated with risk of index HSI (online
supplementary appendix 2: table 3).
Sports performance and match play
Playing position impacted the risk of index HSI in football
(LOE: strong),19 20 45 49 55–57 71 94 97 American football (LOE:
moderate),62 72 rugby (LOE: moderate),12 67 Gaelic football
(LOE: limited)88 and cricket (LOE: limited)85 (online supple-
mentary appendix 2: table 2). Positions that can have larger
running demands resulted in a greater risk of index HSI in foot-
ball (midfielders, defenders and forwards vs goalkeepers),49 56
American football (receivers, defensive backs, running backs vs
linemen)72 and cricket (fast bowlers vs spin bowlers).85 Reduced
between match recovery and/or increased schedule conges-
tion29 63 69 and the level of competition45 83 97 showed conflicting
relationships with HSI risk (online supplementary appendix 2:
table 4).
Clinical and imaging examination of the index HSI
Clinical examination findings of the index HSI at baseline (the
number of previous HSIs;44 reduced strength endurance)21 and
just after return to play (strength; range of motion; tenderness
to palpation)44 were associated with greater risk of recurrent
HSI (LOE: limited) (online supplementary appendix 2: table
5). None of the MRI findings of the index HSI were clearly
associated with greater risk of recurrent HSI whether taken
at baseline or return to play, including conflicting evidence
of an unknown association for intratendinous injury/intramus-
cular tendon disruption54 105 (online supplementary appendix
2: table 5).
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Environmental factors
International travel prior to a cricket match was associated with
HSI (LOE: limited).85 Other environmental factors were unre-
lated to risk of HSI (online supplementary appendix 2: tables 2
and 3).
Discussion
We investigated 179 potential risk factors in a data set of
8,319 HSIs, including 967 recurrences, in over 71,000
athletes. Older age and previous injury were the strongest
risk factors for HSI from meta-­analysis. Athletes who have
any history of HSI are 2.7 times more likely to sustain a HSI
than those without, and they are at an even greater risk if the
previous HSI occurred in the same season (≈5 times). The
influence of these non-­modifiable factors was not consistent
across studies, highlighting the potential modulation of risk by
other factors such as the physical characteristics of the athlete
(eg, strength qualities),22 25 46 106 exposure to load (eg, high-­
speed27 28 and match29 30 running workload) and mechanical
function when performing sport-­related activities (eg, running
kinematics).92 107 In the best evidence synthesis, factors related
to sports performance and match play, running and strength
were most consistently associated with HSI.
Modifiable risk factors
Strength and flexibility qualities were the most investigated
modifiable risk factors for HSI. While baseline strength defi-
cits were associated with a greater risk of HSI in a number
of studies,21 22 44 46 flexibility, mobility and range of motion
provided limited value as stand-­alone risk factors. Strength and
flexibility qualities change over time and fluctuate in response to
exposure (ie, fatigue).14 108 It may not be valid to use data from a
single occasion of baseline assessment to prospectively evaluate
associations with subsequent HSI. Testing procedures may be
better implemented as part of ongoing monitoring rather than
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baseline screening16 and when employed regularly as part of the
clinical management of an index HSI to avoid a recurrence.108 109
This could be especially relevant for susceptible athletes, such
as those who are older, have a history of HSI and a hamstring
strength deficit.24 25 110
Running exposure is another modifiable risk factor for
HSI.27 28 The risk of subsequent HSI is elevated in athletes
exposed to greater high-­speed running loads, especially with
sudden increases (ie, within the previous 7–14 days).27 28 These
athletes may be predisposed to HSI due to the fatigue and eccen-
trically induced muscle damage associated with fast running
activities.111 Graduated exposure may also be advantageous for
resilience to injury mechanisms such as sprinting.112 113 A balance
must be found between inducing positive adaptations that are
protective against HSI and excessive exposure that increases
susceptibility to HSI.113 114
Non-modifiable risk factors
Athletes who are older and have an injury history are often at
greater risk of a future injury.10 16 49 52 115 ‘Old’ is difficult to
define, as age can influence HSI risk in athletes as young as 24
years.52 Age could impact HSI risk because it correlates with
exposure: over time (ie, with older age) athletes are exposed
to greater mechanical loads and the likelihood of encountering
injury mechanisms increases. Small differences in age likely
represent large differences in exposure in elite sport. Age-­
related physical changes may also predispose older athletes to
HSI116 by affecting structural (eg, altered architecture,117 118fibre
type populations,119 120cross-­sectional area,120 121 stiffness122)
and neurological (eg, denervation of high-­ threshold motor
units123–125) qualities.
Previous muscle injury can also result in structural (reduced
biceps femoris fascicle length,118 atrophy,126 scar tissue127) and
neurological (reduced voluntary activation128) maladaptation
within the injured muscle. This may explain reduced hamstring
strength129 130 and a shift towards peak knee flexor torque gener-
ation at shorter muscle-­tendon unit lengths131 following a HSI.
Persistent deficits may reduce the ability of the hamstrings to
tolerate high degrees of stress and strain, contributing to an
elevated risk of recurrence.
A novel finding is that athletes with a history of ACL injury
have a 70% increase in risk of HSI, and a previous calf strain
injury increases the risk by 50%. The mechanisms responsible
for the increased risk following ACL injury are unclear, but
reduced proprioception, strength deficits and altered gait
could contribute.132–134 Susceptibility to HSI following an ACL
reconstruction may also be associated with ongoing hamstring
deficits due to the graft used.135 136 Athletes may be more
likely to sustain a HSI following a calf strain injury because the
hamstrings become less conditioned to tolerate injury mech-
anisms and high-­speed running workloads after a period of
reduced exposure.28 This highlights the importance of holistic
rehabilitation and greater consideration for the risk of subse-
quent HSI when athletes return to play from these injuries.
Recurrent HSI
Clinical data about the history of HSI and persistent hamstring
deficits best evaluate risk of recurrent HSI. Strength deficits,
reduced hamstring flexibility and palpation tenderness at return
to play may indicate an increased risk of recurrent HSI. MRI
descriptors of the index HSI at baseline and return to play do not
accurately predict risk of recurrence.
Green B, et al. Br J Sports Med 2020;54:1081–1088. doi:10.1136/bjsports-2019-100983
Review
Br J Sports Med: first published as 10.1136/bjsports-2019-100983 on 16 April 2020. Downloaded from http://bjsm.bmj.com/ on January 25, 2023 at UFSM - Universidade Federal de Santa
What is already known
►► Older age and a history of hamstring strain injury (HSI) are
strong risk factors for HSI.
What are the new findings
►► Older age and injury history (HSI, ACL injury, calf strain injury)
are associated with an increased risk of subsequent HSI.
►► Key areas to evaluate athletes for information about risk
of HSI are sports performance and match play, hamstring
strength, and running.
►► Clinical examination findings best evaluate the risk of
recurrent HSI.
►► Future research should consider examining the interactions
between risk factors for HSI, along with how these
relationships fluctuate over time, such as over the course of a
competition season.
Implications/future directions
Awareness of risk factors may be useful for athlete management
to mitigate HSI risk. The identification of modifiable risk factors
is an important component of injury prevention models.137 138
Maria. Protected by copyright.
Identifying single risk factors provides some direction for clini-
cians, but fails to account for the complex and fluctuating interac-
tions between risk factors.139 The interactions between potential
risk factors for HSI is accounted for in some investigations,24 140
but further research is needed to fully understand these relation-
ships and how they may influence injury risk.139 Such investiga-
tions may be especially important to guide clinical practice since
HSIs (index or recurrent) unlikely occur because of any isolated
factor.109 110 129
Limitations
As with any systematic review or meta-­analysis, the strength of
these results relies on the quality of the studies included. A lack
of consistency in injury definitions and variable study methods
(see online supplementary table 1), as well as limited consid-
eration between injury types (eg, index vs recurrent HSI) and
mechanisms (acute vs gradual onset injuries),16–18 are limita-
tions of the included studies. Distinctions between index and
recurrent HSI are not always clearly described. Even when this
is defined, the classification of a recurrent HSI often relied on
participant memory, subject to recall bias. Some recurrences
may have been erroneously recorded as an index HSI despite
the presence of an injury history. Given the exclusion of inter-
vention studies, data derived from the control groups in these
studies are not included here. Another shortcoming of the
available evidence is that the sample size and number of HSIs
are often too small to meet the methodological requirements
when investigating these relationships.141 Publication and
language biases are other potential limitations of this review.
Conclusion
Older age, and a history of HSI, ACL injury and calf strain injury
were significant risk factors for HSI. Factors related to sports
performance and match play, running and hamstring strength
are likely important for evaluating the risk profile of athletes,
which reflects the multifactorial nature of index and recurrent
HSIs.
7 of 10
 Review
Correction notice  This article has been corrected since it published Online First.
The title has been amended.
Twitter Brady Green @BradyDGreen, Matthew N Bourne @mbourne5, Nicol van
Dyk @NicolvanDyk and Tania Pizzari @DrTaniaPizzari
Contributors  All authors made equal contributions to the work. All authors
provided permission for the submission and publication of this version of the review.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
ORCID iDs
Brady Green http://o​ rcid.​org/​0000-​0003-​1135-​0033
Matthew N Bourne http://​orcid.​org/​0000-​0002-​3374-​4669
Nicol van Dyk http://o​ rcid.​org/​0000-​0002-0​ 724-​5997
Tania Pizzari http://​orcid.​org/​0000-​0002-8​ 804-​0095
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